A reasoned response

Authorities must prepare for monkeypox

The identification of India’s fourth confirmed case of the monkeypox virus in Delhi over the weekend has brought up questions about India’s preparation for another possibly deadly disease. Last week, the World Health Organization (WHO) declared monkeypox a “global emergency”. The differences from the Covid-19 virus in all its variants, however, must be clearly understood. It is far less contagious as of now, requiring close and lengthy contact for human-to-human transmission to occur. Like the Human Immunodeficiency Virus, or HIV, in its early stages, it is currently seen in the West at least primarily in the LGBTQ (lesbian, gay, bisexual, transgender and queer) community. The WHO’s decision to declare monkeypox a global emergency was not unanimous. It has, after all, been endemic in certain parts of West and Central Africa since the 1970s, and there was an outbreak in the United States in 2003. The virus is zoonotic —transferred mainly between animals and humans — and in past outbreaks many cases were reported after close contact with pet animals such as hamsters and prairie dogs.

Most importantly, research has shown that those inoculated against smallpox — a closely related, though more deadly disease — have strong cross-protection against monkeypox. This has clear public health implications for India. It will be necessary to examine India’s stock of smallpox vaccines and see if it is possible to vaccinate all close contacts of known monkeypox cases. If the virus spreads further, then a general vaccination campaign with third-generation smallpox vaccines might also be useful. The global number of stockpiled smallpox vaccines is 35 million, and it is administered by the WHO — the agency’s most famous success was, after all, the eradication of smallpox in the 1970s. The United States has an additional vaccine stockpile of 200 million doses and is already dipping into it to inoculate high-risk individuals, including health care workers.

The US’s current smallpox vaccine — developed in the 2000s, amid fears of bio-terrorism — is similar to older versions in that it is not always safely usable against some individuals, including the immunodeficient. A Danish vaccine maker, Bavarian Nordic, has developed a vaccine known as Imvanex, which has been cleared by Western regulators for use against monkeypox. The company can produce 30 million doses a year, but the methods used are more complicated than the old smallpox vaccine and therefore it will be difficult to scale up or subcontract production. The US and the European Union are likely to use it to fill in the gaps left by the deficiencies of the smallpox vaccine. India, as a major vaccine producer, may need to check whether its manufacturing capability is useful in scaling up the production of the smallpox vaccine in particular.

The public health system is now sadly familiar with what else needs to be done — contact tracing, institutional quarantines, and keeping an eye out for any dangerous mutations of the virus. If public health systems perform as they should, there will be no reason to fear. Monkeypox is not Covid-19, and particularly not Omicron — which is, by any standards, an unusually contagious virus. The Indian response should be measured and reasoned —but swift and resolute.